Uptake, experiences and barriers to cervical screening for trans and non-binary people in Aotearoa New Zealand.

Little is known about experiences and barriers for trans and non-binary (TGNB) people eligible for cervical screening in Aotearoa New Zealand. AIMS: To identify uptake, barriers and reasons for delaying cervical cancer screening among TGNB people in Aotearoa. MATERIALS AND METHODS: The 2018 Counting Ourselves data on TGNB people assigned female at birth aged 20-69 years who had ever had sex, were analysed to report on experiences of those who were eligible for cervical screening (n = 318). Participants answered questions about whether they had taken part in cervical screening and reasons behind any delays in receiving the test. RESULTS: Trans men were more likely than non-binary participants to report that they did not require cervical screening or were unsure if they needed it. For those who had delayed cervical screening, 30% did so due to feeling worried about how they would be treated as a trans or non-binary person and 35% due to another reason. Other reasons for delay related to general and gender-related discomfort, previous traumatic experiences, anxiety or fear of the test and pain. Material barriers to access included cost and lack of information. CONCLUSIONS: The current cervical screening program in Aotearoa does not consider the needs of TGNB people, leading to delayed and reduced uptake of cervical screening. Health providers require education on the reasons TGNB people delay or avoid cervical screening in order to provide appropriate information and affirmative healthcare environments. The human papillomavirus self-swab may address some of the existing barriers.

Unmet need for gender-affirming care as a social determinant of mental health inequities for transgender youth in Aotearoa/New Zealand.

BACKGROUND: Past studies have demonstrated better mental health and well-being among transgender youth who had accessed gender-affirming care. However, few existing studies have assessed unmet need for gender-affirming care as a social determinant of mental health inequities. METHODS: Data on unmet need for gender-affirming care, distress and suicidality were analysed from the 2018 Counting Ourselves nationwide community-based survey of transgender people in Aotearoa/New Zealand. Associations between unmet need for gender-affirming care and mental health indicators were tested for transgender youth within the sample (aged 14-26 years; n = 608; Mage = 20.5). RESULTS: Transgender youth reported unmet needs ranging from 42% for gender-affirming hormone to 100% for feminizing surgeries and voice surgeries. Overall unmet need for gender-affirming care was associated with worse mental health. Trans men with an unmet need for chest reconstruction (84%) scored an average of 7.13 points higher on the K10 Psychological Distress Scale relative to those whose need had been met. Participants reporting unmet need for hormones (42%) had twice the odds (adjusted odds ratios = 2.01; CI = 1.02-3.98) of having attempted suicide in the last 12 months. CONCLUSIONS: Dismantling barriers to accessing gender-affirming care could play a crucial role in reducing mental health inequities faced by transgender youth.

PrEP awareness and protective barrier negotiation among transgender people attracted to men in Aotearoa New Zealand.

INTRODUCTION: Internationally, trans women are disproportionately impacted by HIV, encounter specific barriers navigating safer sex and face inequities accessing HIV prevention, including pre-exposure prophylaxis (PrEP). Aotearoa/New Zealand (hereafter Aotearoa) was one of the first countries internationally to publicly fund PrEP in 2018, including for trans people. However, few data exist on PrEP awareness or sexual negotiation among trans populations to guide implementation. We present the first Aotearoa data on trans people's ability to negotiate barrier protection and awareness of PrEP efficacy and availability. METHODS: We used data from a large, diverse community-based nationwide survey of trans (including non-binary) people in Aotearoa: Counting Ourselves (N = 1178) conducted from 21 June to 30 September 2018. Generalized regression analyses were carried out among participants who have had sex (n = 704; Mage = 32.5) to identify associations between demographic factors (age, gender and sexual attraction, ethnicity, income, education qualification and current sex work involvement) and the Trans-Specific Barrier Negotiation Self-Efficacy (T-Barrier) Scale and PrEP awareness. RESULTS: The mean value of a 40-point T-Barrier Scale was 33.45 (SD: 6.89), suggesting a relatively high perceived ability among our participants to negotiate protective barrier usages in different situations. Asian participants scored 3.46 points lower compared to Pakeha (White) participants, and trans women attracted to men (cisgender and/or trans men) scored 2.40 points higher than trans women not attracted to men. Three-fifths (59.7%) were aware that PrEP reduced HIV risks and did not prevent sexually transmitted infections (STI) transmission, and only two-fifths (40.2%) knew PrEP was publicly funded for trans people. In multivariate models, we found participants who were older, trans women or those with lower education qualifications were less likely to have increased levels of PrEP awareness. CONCLUSIONS: Participants attracted to men have a higher potential need for PrEP and were more likely to report PrEP awareness and that they could negotiate protective barrier usage. However, trans women and those with lower educational qualifications reported lower levels of PrEP awareness. More trans-competent sexual health education, drawing on the newly released PrEP guidelines, is needed to promote the benefits of PrEP in the Aotearoa HIV epidemic context, particularly for trans women.

"Being Trans Intersects with My Cultural Identity": Social Determinants of Mental Health Among Asian Transgender People.

Purpose: While studies on the relationship between social determinants and mental health among transgender people in Asia are increasing, there is a paucity of research on Asian transgender people living in Western countries. This study aimed to examine how social positions (gender, ethnicity, and migrant status) and social determinants of mental health were inter-related for Asian transgender people in Aotearoa/New Zealand. Methods: We analyzed both quantitative and qualitative data from Asian participants (n=49) who responded to the 2018 Counting Ourselves: Aotearoa New Zealand Trans and Non-Binary Health Survey. Results: Overall, 35% reported a very high psychological distress level. There were high levels of unmet needs for gender-affirming care, and participants reported a range of negative experiences at health care settings. About two-fifths had been discriminated because of their transgender (42%) or Asian (39%) identities. Fewer than half of participants felt that their family members were supportive of them being transgender (44%), and most reported they had supportive friends (73%). More than two-thirds of participants (68%) had a strong sense of belongingness to the transgender community and 35% reported this for the Asian community. Qualitative findings revealed specific challenges that participants experienced; these included barriers to accessing health care due to their migrant status and language barriers, influences of Asian cultures on mental health experiences, and rejection by family and people in Asian communities. Conclusion: Our study provides evidence for health care providers, researchers, and policy makers to employ a culturally appropriate lens to improve knowledge about the intersectional experiences of being Asian and transgender.

"I teach them. I have no choice": experiences of primary care among transgender people in Aotearoa New Zealand.

AIM: This study aims to report primary care experiences among transgender people in Aotearoa New Zealand based on quantitative and qualitative data from a nationwide community-based survey of transgender people. METHODS: Subsamples with a usual general practitioner were employed from the 2018 Counting Ourselves Survey (n=871) and the 2018/19 New Zealand Health Survey to assess inequities between these samples in primary care experiences and barriers. Guided by Andersen's Behavioural Model of healthcare access, we conducted a content analysis on comments from Counting Ourselves participants (n=153) to identify themes about issues of concern for transgender people when accessing primary care. RESULTS: Transgender participants had greater risk of feeling no confidence in their GPs (Mdifference=0.22; Cohen's d=0.39), reporting barriers accessing primary care due to cost (38.4% vs 17.4%; RR=2.21), and transport issues (13.5% vs 3.0%; RR=4.58) compared to the general population. Content analysis uncovered how transgender people's primary care experiences are shaped by healthcare environments, predisposing characteristics, and enabling resources. CONCLUSION: Our findings indicate ways to ensure primary care services are inclusive so that all transgender people feel welcome. This requires all primary healthcare professionals to demonstrate core trans-specific cultural safety when providing healthcare to transgender patients.

Barriers to Possessing Gender-Concordant Identity Documents are Associated with Transgender and Nonbinary People's Mental Health in Aotearoa/New Zealand.

Purpose: This study sought to expand on previous scholarship focused on gender-concordant identity documents (IDs) as a social determinant of health. We examined the association between barriers to legal gender recognition and the mental health of transgender and nonbinary people in Aotearoa/New Zealand. Methods: We used data from a 2018 nationwide community-based survey of trans and nonbinary people in Aotearoa (N = 818). Variables of investigation included: gender-concordant IDs, mental health (past-month psychological distress, past-year nonsuicidal self-injury, past-year suicidality) and barriers to changing gender markers on a birth certificate or passport. Associations between gender-concordant IDs and mental health were determined using generalized linear regression models. Results: In total, 34.8% reported the correct name on all of their IDs. The proportion with the correct gender marker on both birth certificates and passports was 16.0%. Participants with gender-concordant IDs were more likely to be older, have higher levels of income and education, and have had genital reconstruction. In addition, 68.7% of participants reported experiencing at least one barrier to changing gender markers on their IDs, and these participants had significantly higher average points of psychological distress scores (b = 2.39) and greater odds of suicidal ideation (odds ratio = 2.02) than those with gender-concordant IDs, after adjusting for sociodemographic variables. Conclusion: We present novel findings on higher levels of mental health problems among trans and nonbinary people who faced barriers in trying to obtain gender-concordant IDs compared with those with gender-concordant IDs. Removing barriers to legal gender recognition may be an effective way to improve mental health.

Supportive interactions with primary care doctors are associated with better mental health among transgender people: results of a nationwide survey in Aotearoa/New Zealand.

BACKGROUND: Past research has established that transgender people experience significant disparities in mental health outcomes and healthcare dissatisfaction compared with cisgender people, but more research is needed on how supportive healthcare interactions relate to the mental health of transgender people. OBJECTIVES: The 2 main aims of our analyses were: (i) to establish the most common negative experiences in healthcare and the most common supportive experiences specifically with primary care doctors for transgender people; and (ii) to examine the association of supportive experiences with mental health variables after controlling for demographic factors. METHODS: Data from the 2018 Counting Ourselves nationwide survey of transgender people were analysed using regression modelling. The 948 participants with a primary care doctor or general practitioner were included in analyses. Participants were aged 14-83 years old (mean 30.20). RESULTS: The most common supportive experiences involved primary care doctors treating transgender people equitably, with competence, and with respect. Participants with more negative healthcare experiences had higher psychological distress as well as higher likelihood of reporting nonsuicidal self-injury and suicidality. Conversely, participants with more experiences of supportive primary care doctors had lower psychological distress and were less likely to have attempted suicide in the past 12 months. CONCLUSION: When transgender people receive supportive care from their primary care providers they experience better mental health, despite ongoing negative healthcare experiences. Future research is needed to confirm ways of supporting positive trajectories of mental health for transgender people but these findings demonstrate the importance of positive aspects of care.

Mental health of people of diverse genders and sexualities in Aotearoa/New Zealand: Findings from the New Zealand Mental Health Monitor.

ISSUES ADDRESSED: To examine the mental health inequities, and social exclusion and isolation and protective factor differences between people of diverse genders and sexualities (lesbian/gay, bisexual, gender diverse and takatapui) and cisgender and heterosexual people in Aotearoa/New Zealand. METHODS: We employed data from the pooled probability sample of 2016 and 2018 New Zealand Mental Health Monitor. The sample comprised of 2938 people at least 15 years old, of which 93 had diverse gender and sexuality identities. Generalised linear models were used to test for differences in mental health (current and lifetime mental distress, depression, anxiety, self-harm and suicide), social exclusion and isolation, and friend and family support for people of diverse genders and sexualities. We also conducted exploratory linear regression analyses to examine whether mental health difficulties were associated with social exclusion and isolation and friend/family support. RESULTS: People of diverse genders and sexualities had high rates of mental health difficulties across all variables we examined. For example, people identifying as diverse genders and sexualities had three times the risk of considering self-harm and suicide than their cisgender and heterosexual counterparts (22% vs 5%; RR = 3.12). People of diverse genders and sexualities also scored an average of 6.08 points higher on the 27-point PHQ-9 depression scale when they had experienced social isolation, and 4.01 points higher when they experienced social exclusion. CONCLUSION: Our results are consistent with current literature on the large mental health inequities faced by people of diverse genders and sexualities. SO WHAT?: Policy makers and health care providers in Aotearoa/New Zealand should consider the negative mental health consequences of social exclusion and isolation for people of diverse genders and sexualities.

Enacted stigma experiences and protective factors are strongly associated with mental health outcomes of transgender people in Aotearoa/New Zealand.

INTRODUCTION: International evidence has found large mental health inequities among transgender people and demonstrates that mental health outcomes are associated with enacted stigma experiences and protective factors. This study aimed to examine the extent of associations of enacted stigma experiences specific to transgender people alongside protective factors with mental health of transgender people in Aotearoa/New Zealand. METHODS: The 2018 Counting Ourselves survey was a nationwide community-based study of transgender people (N = 1178, Mage = 29.5) living in Aotearoa/New Zealand. The survey assessed a wide range of gender minority stress experiences and protective factors that comprised primary (support from friends and family) and secondary social ties (neighborhood and transgender community belongingness). We calculated the predicted probabilities that transgender people exhibit very high psychological distress level, non-suicidal self-injury, and suicidal risks with different combinations and exposure profiles of enacted stigma and protective factors. RESULTS: Our findings demonstrated that enacted stigma was associated with negative mental health, and support of friends and family was linked to better outcomes across all mental health measures. Beyond primary social ties, sense of belongingness to neighborhood and transgender communities were linked to reduced odds of psychological distress and suicidal ideation. For those scoring high on enacted stigma and low on protective factors, our model revealed a 25% probability of attempting suicide in the last year compared to 3% for those scoring low on enacted stigma and high on protective factors. CONCLUSIONS: Echoing previous findings, this study demonstrates that transgender people across Aotearoa/New Zealand are less likely to manifest life-threatening mental health outcomes if they experience low levels of enacted stigma and high levels of access to protective factors. Our findings suggest a need to address the enacted stigma that transgender people face across interpersonal and structural settings, and also to enhance social supports that are gender affirmative for this population.

Mental Health Inequities among Transgender People in Aotearoa New Zealand: Findings from the Counting Ourselves Survey.

There has been little international research looking at differences in mental health across different age groups. This study examines mental health inequities between transgender people and the Aotearoa/New Zealand general population from youth to older adulthood. The 2018 Counting Ourselves survey (N = 1178) assessed participants' mental health using the Kessler Psychological Distress Scale (K10) and diagnoses of depression and anxiety disorders, questions that were the same as those used in the New Zealand Health Survey. Our results showed significant mean score differences for transgender people on K10, and these differences were almost two standard deviations higher than the general population (Cohen's d = 1.87). The effect size differences, however, decreased from youth to older adults. Regression analyses indicated trans women were less likely to report psychological distress than trans men and non-binary participants. There was an interaction effect for age and gender, with lower psychological distress scores found for younger trans women but higher scores for older trans women. The stark mental health inequities faced by transgender people, especially youth, demonstrate an urgent need to improve the mental health and wellbeing of this population by implementing inclusive institutional practices to protect them from gender minority stress.

Gender Minority Stress: A Critical Review.

Past studies that compare cisgender to transgender (or trans) and gender diverse people have found a higher prevalence of mental health problems among the latter groups. This article uses Testa's gender minority stress framework, which is an expansion of minority stress theory, to assess minority stressors that are specific to the experiences of trans and gender diverse people. The concept of cisnormativity, an ideology that positions cisgender identities as a norm, is used in relation to the gender minority stress framework to describe the marginalizing nature of social environments for trans and gender diverse people. This article provides a critical review that integrates and expands on past theoretical perspectives on gender minority stressors and protective factors. Specifically, this article demonstrates the relevance of cultural and ethnic backgrounds to complement the application of intersectionality in research on health disparities experienced by trans and gender diverse people.